The Frightening Phenomenon of Hospital-Acquired Delirium
When a loved one goes into the hospital, the last thing you’d expect is that they would suddenly turn into someone else overnight.
But that’s what can happen with a little-known phenomenon called “hospital-acquired delirium.” Because it occurs frequently, our primary care doctors in Delray Beach want to let you know what it is, and what you can do about it.
Sudden Onset
Writing in the New York Times, author and producer Susan Seliger detailed how her “lucid and whip-smart” 85-year-old mother fell and broke her hip. She survived the surgery with no problem.
“But within 24 hours, a totally different woman seemed to have taken over her capable mind and body,” she says.
“She was disoriented. ‘This isn’t a very nice hotel,’ she told us in the hospital room. ‘They haven’t even served cocktails. Let’s go.’ ”
Her family laughed it off, thinking it was the anesthesia, but things quickly deteriorated. She began having trouble breathing, then tried to rip off her oxygen mask and IV tubes.
“She frantically tugged at the sheets and her skimpy hospital gown,” Seliger writes. “Like the aged Lady Macbeth, she kept saying: ‘We have to clean this up! Clean this mess!’ ”
Seliger’s experience with her mother’s episode was unfortunately not unusual.
A Common Occurrence
“A 75-year-old man is admitted for major abdominal surgery. He is functionally independent, with mild forgetfulness. His intraoperative course is uneventful, but on a postoperative day two, severe confusion and agitation develop. What is going on?”
This case vignette begins a New England Journal of Medicine (NEJM) feature exploring what it calls an “extremely common problem in hospitalized older adults.”
In fact, the author, geriatric medicine specialist Dr. Edward R. Marcantonio of Beth Israel Deaconess, says, “One-third of general medical patients who are 70 years of age or older have delirium.
“Delirium is the most common surgical complication among older adults,” he writes, “with an incidence of 15-25 percent after major elective surgery and 50 percent after high-risk procedures such as hip-fracture repair and cardiac surgery.”
The prognosis for recovery is mixed. Most people return to normal within a week or two after returning home. Recent studies, however, have found that people over age 65 who were admitted to a hospital and were diagnosed with delirium were more likely to die within a year than those who hadn’t. And the episodes of delirium may continue for months after discharge in up to a third of patients.
Possible Causes
There are many reasons why a patient might exhibit hospital-acquired delirium. These include:
- Sleep deprivation—The constant noise, lights, interruptions, and general activity in a hospital setting can make a peaceful night’s sleep impossible. This naturally leads to a confused mental state.
- Undiagnosed infections—Many untreated infections can cause delirium. Urinary tract infections are the most common culprit in a hospital setting.
- Dehydration—It may sound too simple, but dehydration can lead to delirium.
- Drug reactions/interactions—Older adults are often taking multiple medications, and new ones may be introduced at the hospital, causing unforeseen reactions or interactions. Conversely, the sudden withdrawal of medications can also cause such a reaction.
Medical Missteps
Another possible cause is a medical staff that doesn’t understand what’s happening or how to properly react to it.
In the case of Seliger’s mother, her doctors did what experts say not to do.
“They tied her hands to the bed. The medications to calm her down didn’t work. The doctors upped the sedation,” she writes.
Dr. E. Wesley Ely, a professor of medicine and critical care at Vanderbilt University School of Medicine, later told Seliger that this type of delirium actually resulted “in large part” from the actions of medical workers.
“Even well-meaning doctors are doing damage without knowing it,” he said. “This dysfunction is grossly under-recognized.”
And because patients in the hospital are transient and the medical staff may not know them, they may tend to attribute the condition in seniors to dementia, although the two are not the same. Dementia develops slowly over months or years. Delirium is characterized by its sudden onset and includes confusion, disorientation, and sometimes hallucinations.
How to Help
It’s vital that hospital staff rule out physical causes for unusual behavior in a patient, such as treating infections or performing tests for a possible stroke. The use of physical restraints and sedatives is not recommended, because they can worsen the patient’s condition.
If your loved one is hospitalized and experiences hospital delirium, here are some things you can do.
1. Try to spend as much time as possible with them. Make sure they have such necessary items as glasses, hearing aids, and dentures. Bring family photos or other familiar items to help reorient them.
2. Ask the staff to minimize sleep deprivation, waiting until morning to do blood pressure checks or give medication, for example. Also, ask that lights are lowered and that noise is kept to a minimum at night to allow for restful sleep.
3. Encourage exercise. Even a brief walk down the hall two or three times a day will help.
4. If you tell them their hallucinations are not real, they likely won’t believe you. Remain calm, reassure them you are there to look out for them and try to redirect their thoughts into their surroundings casually.
Remember, once they are out of the hospital setting, chances are they will return to normal.
